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r DEPAR']'MENT OF COM �NITY&DEYELflPMEN'C SERYICES
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CITY OF DIAMOND BAR
INSPECTIt}N RECORD �
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FOOTINGS fORHiS SWITGti GEAR --
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SI..AB COMftfiERGIAL H�OD
UG PLUMBING 7-BAR
lIG ELECTRICAL INTERGEPTER
UFER GR6UNp HOT MDP1SfiQWERPAN
SENfER LATERAL SEPTICIGESSPDO�
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MAIN WATER LINE MEHS REPORT IiEGEiVED
SEWER GlEANOUT �' 6EPA4LITfON
ROOF SNEAtNING ' ROOF DRFiINS
ft00H SHEATHING R�UGH CON�UIT
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SHEAR WAI.LS INTERIOFi ROIJGH PLUM�ING
FRAMINCVVENTING ''��� RDUGH ELECTRICAL
ROUGH MEt�iANiG4L ROUGH MECHANICAL
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R011�H PLUMStNG � �'��,PRE GUNITE
INSUUITI6N WAII. �'��..P�OI PHE 4ECK BONOING
INSUlAT16N CEILIN� P-TRAP
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ELECTRIC MEfER RELEASE WAl1 DEiAiNJ SEAL
GfIS METER AELEASE WAI.L FINAL
SPEGIpL INSPECTION Fi0 ftiPN�i6PtAt+�J1N�AP{'RQt+AL
FINAI.BlliLDING 'iiOUGH FiRE APPfi0YA1
PINAL MECHANICAL . � �''���.HMAL FIRE DEPAHTMENT
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Building& Safety IJiviaion
21810 Copley I}rive
Diamand Baz,California 41765
{904}839-7020 Fax (9tK!}$61-3117
Job AddreSs C/��.�' ('nyi o.J �j�Ji�?�'�'`�f'�(+et��—�'1tJ' . Gf� gf ��i�
Dear Property 4wner
An application far a building �rmit has been submitted in your name sta#�ng yourseif as ttre butlder of tha �
pro�rty emprovements spe�rf'ied
For your protectian, you should be aware that as"owner-bu0der"ycsu are the respons+ble pariy of record on
such a permit Buddmg permds are not requtred to be s�gned by property owners unless they are persanatiy
performing their oam wqrk If your work�s�ing performed by someone other than yourseif, yau rnay protect youtself
frarn pt�ss�ble habtlity�f that person apphes for the proper permd in his ar her name
Contractors are requ�red by law to be licensed and kronded by the State of Gabfomia and to have a bus�ness
f�cense from the C�ty of County They are also requ�red by law to put the�r I�cense number on all permits ft�r which they
�PP�Y
if you employ or athervwse engage any persons ather than ycaur�mmedia#e famdy, and the wcark pncludmg
matenais and o#her casts} is$2�0 p0 or more fa�the entve proaect, �nd such persons are not boensed as contractors
or subconh-BGtors,then you rnay be an employer
If you are an emp3oyer, you must reg�ster wdh the state and federai government as an employer and you are
subteCt to several obhgahons includmg sta#e and federal mcame tax withhpld�ng, federal soC�al seCur�ty taxes,warkers
compensaUon insurance, disabtlity insurance costs, and unempioyment campensatron contnbufions
Thete m�y be financiel nsks for you if you do not carty out#hese obhgabons, and these nsks are especially
serious with respect to workers cc>mpensation insurance
Far more specific�nfarmation at�ut your obligatit�ns undet the federai Iaw, contact the Intemal Review Setv�ce
(and if you wish,the U S Small Business Adm�rnstration) For more speaflc mformation about your t�bligations under
State law, contack the Qepartment of Benefrt-Payrnents and ttre D�v�sion of Industnai Accidents
If the sUvcture is intended far sale, the pro�rty owners who are not 6censed contractcars are aflaw�!to
perfortn their work personally or through their own empi4yees, without a licensed contractor ar subccmtractor, oNy
under i�m�ted cond�dons
A frequent prau�ce of unircensed persans professmg to be contractors�s to s�ure an"owner-budde�'butldmg
�rmit, erroneousiy �mplying that the peoperty owner is providing his or her own labor and matenals persanally
Bu�idmg perm�ts are not requ�red to be signed by the properiy qwners uniess they are performing their own work
persanally
informat�on at�ut hcensed contractors may be pbta4ned by contacUng the Gantractors State��cense Board at
9821 Bus�ness Park Dnve, 5acramento, CA 95827,www csib ca aov ar at(800)321-CSLB (2752}
Piease compiete and retum the enclosed"Owner-Budder"venficat�on forrn so that we can confirm that you are
aware of these matters The buUdmg pemrit wdl not be�ssued until the versficaUon is returned
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Bailding&Safety Divisian
21825 Capley Lhive
Uiamond Bar,Califamia 91?tr5
{909)839-?020 Fax{909)861-3127
AttenGon Property Owner
An"Qwner-Budder budd�ng permit has been apphed htr in your name and �aring your sagnature
Please compiste and retum this rnfarmaUan at your earliest opporturnty ta avoid unnecessary deiay m processing and
�ssuing your budding permit No building perm�t witt be issued undi th�s venficabon is received by us
1 I personaliy pian to prov�de the ma}or labar and matenals for construction of the ptoposed properiy
improvement{yes or no) A/�
2 f {havethave nat} _��_ signed an applicat+an f�r a bwidmg permit for the proposed vrork
3 1 have contracted Hnth#he fallaanng persan (ftrm}to provide�he proposed�nstrucUon
Name T{�ci R� Address Fi f 3� /'��{aot Z�J' ���Y ��'veisr'tr{{'.
Phone _(9�`f}��3_�3,3� Gonkractors�+cense No 7�'S�b !
4 I plan to prov+de portrans of the work, but I have hired the faliawmg persarr to cocardinafie, supernse and
provide the ma�or work
Name Address City
Fhc�ne ConUactors License No
5 I will ptov�de some of the u+�rk but i have contracted(hired}the foflo�nnng persons to provide the wark
mdicated
hlame Address Phone Type of Work
--'l
S��ned
�,—~�l�Ownet
Date f���f("
. � .
N4TICE Td PROPERTY OWNER
Dear Prpperty Owner
An application far a buddmg permd t�s been subm�tted in your name IisUng yourseif as the budder of the property
improvementsspeci8edet 4S8 ('n✓arpd /,.l:ann �r �1'7rwna�u� � . GR �t7b5�
We are prov�ding you vinth an Owner-Budder Acknowledgment and informaUan Venftcati4n Form ta make you aware of
your responsibd�t�es and possfbie nsk you may i�cur by having th��peRrnt�ssued in your aame as the Owner-Budder
VYe vnli not issue a bu�Idrng pqrmrt unbl you have read, m�Ualed your understandmg of each prowsion, signed, and
retumed this farm to us at our Qificial address �ndicated An agent flf the axmer cannot exe�ute ttris nfltice unless you,
the property awner, obtam the pnor approvai of the permitting authanty
{}WNER'S ACKN{}tAti_EDGEMENT AND VERIFIGATIt}N
DIREGTIONS Read and inft�al each statement 6elow to sigmiy you unders#�nd or venfy this mformaUon
�' 1 I understand a frequent prachce of un#��nsed persons is to have the property owrrer obtam an "Owner-
Buddee" butld�ng permit that erroneo�siy imphes that#7e property owner�s prowdmg his or her awn Iabar and mater�ai
personally I, as en t}wner-Builder, may be held hable and subaect to senous financial nsk for any in�unes sustained by
en unhcensed person and his or her employees whde warking fln my pmperly My hom�wner's insuranc� may not
provide c�verage for those �nJunes I am wdlfuily actmg as an Owner-Budder and am aware af the I�mits of my
�nsurance c�verage for in�unes to warlcers on my property
�,2 I understend buddmg permits are not required ta�signed by properry owners uniess they are respans�ble for
the cansWctifln and are not hinng a licensed Gpntractor#a assume this rnsponsibddy
�3 I understand as en"t}w�er-Budder" i am ttre rssppns�bie party of recard on the permd I understand that i may
proteck myself ftom potential financiai nsk by h�r�ng a i�s�nsed Contractor and having the permd filed in his or her name
rnstead flf my own
�4 I understend Contractors are requ�red by law to be Iicensed and bonded m Califomia and tfl list their i�cense
numbers on peRn�ts and c�ntracts
�5 1 understand �f 1 employ or atherwise engage any persons, okher than California��censed Cantractors, and the
totai value of my conskrvctron is at leask five hundred doitars{$5�0), includmg iabar and matenals, i may be cansidered
an "empioyer"under state and federal law
�6 I understand if I em cans�dered an "empioye�' under state and f�:deral iaw, I must register w� the state and
federai government, withhold payroii taxes, prov�de warkers' campensation disab�lity msurance, and contnbute ta
unemployment compensat�on for each "employee " I also understand my fa�lure to abide by these laws may subaect
me ta senous finanaal nsk
�7 f understand under Cai�fomia Cantractors' State license �aw, an Owner-Buddee who budds single-famiiy
residerrtial structures cannot Iegaliy butld them wGth the �ntent to offer them for sale, uniess all work i� perforzned by
I�Censed subcontrachors and the number pf structures does not exceed four withm any catendar year, or aII of the wqrk
is perfo�rned under conhact with a hcensed general butldmg Contractar
�. 8 I understand as an f}wner-Butlder if 1 seiE the ptpperty for wh�ch this perm�t�s �ssued, I may � heid liable for
eny financial or persanal in�unes susta�ned by any subsequent owner(s}thet result from any latent construction defects
in the woekmansh�p ar matenals
�� I understand I may ohtain more mfarmation regarrlmg my obhgations as en "employet" from the Intemal
r 'Revenue Serv;ce, the United States Small Busmess Admirnstra�on, the Califomia Department af Benefit Payme�ts,
and the Cahfom�a Diwsi4n of Industnal As:cidents i alsa understand I may cont�t the Ca6famia Gontractors' State
�rcense Board (CSLBJ et 7-844-321-GSLB{2752) or www csib ca aov far more�nformahon e6aut hcensed contractors
�10 I �m aware of and consent ta an Owner-Bwider hudding permit applied for m my name, and understand that i
am the party Iegally and finanaally respons�ble for proposed construchon acbvity at the folloonng address
�11 I agree that, as the party legaliy end flnancialiy responsible far this proposed construcUon act�vtty, I wdl abide
by aii applicat�ie laws and requrrements that govern Owner-8utlders es weii as empioyers
� 12 I agree #o noMy the �ssusr of th�s form �mmediately of any addd�ons, delet�ons, or chenges to any of the
informahan i have provided on this farm L�censed cantract+xs are regulated by laws designed ta protect the pubiic If
you cantract with someone who does nat heve a Ircense, Rhe Gontractors'State License Board may be unabie to assist
you wdh any �inanciai ioss you may sus#am as a result of a complai�rt Your only remedy against uniicensed
Gontractors may be in crvii couR tt�s also important fflr you to understand that�f an un6censed Contrackar or empkayee
of that indiv�dual or flrm is �n�ured whde work�ng an yaur pro�rty, you may be held Iiabls fnr damages If}rou obtam a
perm�t as Qwner-Budder and vnsh to hire Cantractors, yau wdl be responsibie far venfying wtrether or not thase
Contractors are proper�y I�censed and the status of their warkers'compensahon msurance coverage
Before a budding permit can be issued, this form mus#tae completed and signed by the property owner end retumed to
the agency t�esponsible fqr issuing the permit
tJote A c�py of the property owne�'s dnver's bcense, form no#anza�on, pr other venficabon acxepteb4e to the agency�s
required to be presented when the perrnd is�ssued ta verify ttre property owner's signature
Signature af Property Owner _..--��"!— .7/ Date �f1�,